Author: WorkCompAcademy

Catastrophic thinking, perceived injustice, entrenched beliefs and fear avoidance. You can call these combined psychosocial risk factors the elephant in the room when it comes to their negative impact on claims outcomes.

At a presentation Thursday at the National Workers’ Compensation and Disability Conference® and Expo in Las Vegas, Darrell Bruga, the founder and CEO of LifeTEAM Health, laid out a game plan for mitigating these factors.

Known as a progressive goal attainment program, Bruga outlined the ways that injured workers, who might have a defeatist mind-set, can be re-engaged and brought back to a more fulfilling life, one that includes a working income.

LifeTEAM is conducting a pilot program with Southern California Permanente Medical Group. Dr. John Harbaugh, an occupational medicine physician director at Permanente was Bruga’s co-presenter.

That path back involves activity coaching, so that someone who has been off work for months can be aided in finding activities to create more structure in their life and build confidence. Such a “disability intervention” Bruga said, can be started in a matter of weeks.

“Ideally, you are engaging this person early on,” Bruga said.

The obstacles to a healthy mind-set in an injured worker can be formidable and deep-rooted however, Dr. Harbaugh said.

Abuse in childhood, whether it be physical violence, sexual abuse, or the psychic chaos created by an alcoholic or drug-addicted parent, greatly increase the possibility of work performance problems and a delayed recovery after an injury, Harbaugh said.

A permanent disability settlement, Harbaugh said, is nothing more than a veiled “pathway to poverty.”

Gene therapy – a risky approach aimed at fixing the malfunctioning genes at the root of some diseases – is finally emerging from its own darkness after weathering high-profile tragedies, including the death of a teenage patient. And, according to the story in the Washington Post, as it evolves from experimental to applied medicine, gene therapy might soon find itself steeped in a new controversy: soaring drug prices. No therapy is approved yet in the United States. But industry leaders are already talking about massive one-time price tags that could make insurers and patients balk. A gene therapy approved in Europe in 2012 costs close to $1 million, and prices are expected to follow suit in the United States. And the industry anticipates the potential backlash against a seven-figure price tag.

As basic research moved forward, excitement about gene therapy soared. But, that initial exuberance would die down as the powerful idea of replacing broken genes collided with the inherent complexity of human biology. In 1999, an Arizona teenager named Jesse Gelsinger died after he experienced an unexpected, severe immune reaction while participating in a clinical trial of gene therapy led by researcher James M. Wilson at the University of Pennsylvania.

Wilson became the subject of legal action and scathing media coverage. The government restricted his work on human subjects. Lawmakers on Capitol Hill held hearings to probe the lack of oversight and the ethical lapses that had marked some gene-therapy trials. Also in the early 2000s, a few patients in a French gene-therapy trial developed leukemia. Along with the Gelsinger case, it proved a tipping point. Private investment in the field rapidly dried up, and a “nuclear winter” followed. Regulators halted dozens of trials.

Gene therapy’s comeback started with a trickle. In 2008, researchers reported that a small number of patients with an inherited form of blindness gained modest improvements in vision with gene therapy. Not long after, gene therapy restored immune function in eight of 10 children with typically lethal “bubble boy” disease. Katherine High, a researcher at the Children’s Hospital of Philadelphia who worked on one of the early blindness trials, started getting cold calls from investors and from pharmaceutical companies, asking if they could partner with her. Then the team of experts she had assembled in Philadelphia began to get job offers.

Today, many companies have treatments in the pipeline. UniQure’s drug, Glybera, in 2012 became the first gene therapy approved in Europe, for a rare metabolic disease. Bluebird Bio, a biotechnology company that went public in 2013, is developing a variety of gene therapies, including a treatment for a genetic blood disease. Regenxbio, where Wilson serves as chief scientific adviser, went public in September.

But the potential sticker shock from a million-dollar drug – even if it’s for a previously incurable disease – is sure to raise some of the same questions from politicians and the public. Spark Therapeutics’ gene therapy is estimated to cost $500,000 per eye. Spending on hemophilia B a gene therapy could conceivably be priced as a one-time payment of $4 million to $6 million. Spark Therapeutics chief executive Jeffrey Marrazzo is reluctant to talk about a dollar figure.

Eight medical professionals and associates are charged in federal grand jury indictments with buying and selling patients in a bribery scheme involving $25 million in improper claims for medical services and devices which were then billed to California Workers’ Compensation insurance companies.

FBI agents along with investigators from the California Department of Insurance and the San Diego County District Attorney’s Office served five search warrants and three seizure warrants at locations in San Diego, Chula Vista, National City, Murietta and Los Angeles. Five people plus six corporations, are charged in three federal grand jury indictments with conspiracy and honest services mail fraud. The indictments allege that these players either paid or received tens of thousands of dollars to buy or sell hundreds of patients, without the patients’ knowledge – therefore depriving those patients of their right to their doctors’ honest services.

“Today’s indictments are only the first wave of charges in what we believe is rampant corruption on the part of some physicians and chiropractors in their dealings with the health care system in general, and California’s Workers’ Compensation System in particular,” said U.S. Attorney Laura Duffy. “This criminal network bought and sold patients like cattle,” said District Attorney Bonnie Dumanis.

One of the indictments alleges that Los Angeles radiologist Ronald Grusd paid bribes to a San Diego chiropractor in exchange for patient referrals. The bribes were funneled to the chiropractor via Grusd’s corporation, Willows Consulting, a shell company. The checks were labeled “professional services,” but this was a sham. In order to further hide the illegal kickbacks, checks were allegedly issued to intermediaries – defendants Alexander Martinez and his father, Ruben – through their front companies, “Line of Sight” and “Desert Blue Moon.” The Martinezes allegedly took their “cut” and then, in turn, paid off the chiropractor.

Grusd’s practice, California Imaging Network Medical Group, has clinics in San Diego, Los Angeles, Beverly Hills, Fresno, Rialto, Santa Ana, Studio City, Bakersfield, Calexico, East Los Angeles, Lancaster, Victorville and Visalia.

In another indictment, allegations say a second San Diego chiropractor, Dr. George Reese, with offices on El Cajon Boulevard, referred patients to a Los Angeles area medical service provider (controlled by attorney Lee Mathis, 70, of San Clemente, and Fernando Valdes, 50, of Westminster, president of Foremost Shockwave Solutions ) in return for bribes. The bribes were set by the conspirators at $100 per patient and paid through an intermediary. After taking a cut amounting to $25 per patient, the intermediary would pay the remaining $75 per patient to Reese. Mathis and Valdes were not arrested, but were ordered to appear in court.

Although disguised as “office rent” payments, the illegal bribes were paid in cash during clandestine exchanges in restaurants and parking lots. For example, $6,000 in cash was allegedly delivered to Reese in the parking lot of the Jolly Roger in Oceanside, hidden in a gift bag. Other times, it was passed in envelopes or stashed inside newspapers. According to the indictment, Reese and his codefendants generated and submitted bills to insurers totaling in the tens of millions of dollars. Most of these treatments involved the providing of “Shockwave therapy,” which uses low energy sound waves to initiate tissue repair. Proceeds from the insurance claims generated through this scheme were allegedly paid to Mathis and Valdes.

In the final indictment, a San Diego chiropractor referred patients to a licensed provider of durable medical equipment, Julian Garcia. In return Garcia paid the chiropractor $50 for each patient – in cash, to disguise the kickbacks. Garcia then improperly billed Workers Comp insurers millions for hot and cold packs for patients who had been secured by bribes.

Governor Jerry Brown signed a bill that provides employers with a limited window to correct technical violations in itemized wage statements before being subject to costly litigation. AB 1506 is a bi-partisan effort to strike a balance between protecting the integrity of wage statements and providing relief to employers from potential litigation over minor paperwork violations. The bill, which received unanimous support in both the Assembly and Senate, includes an urgency clause that allowed it to immediately become law after signed by the governor .

In recent years, there have been a number of cases in which employers were sued under the Private Attorneys General Act (PAGA) over minor, hyper-technical violations of existing law. PAGA requires employers to provide accurate itemized wage statements – and allows employees, through an attorney, to file what is called a “representative action” against an employer for any violation of the California Labor Code related to paystubs.

Because PAGA penalties can be high, and the cost of defending them substantial, some employers have opted to settle employee claims rather than contest them in court. And a handful of legal firms around the state have made a lot of money convincing clients to go after their employers for PAGA-related claims.

But AB 1506 now allows employers up to 33 days to cure any alleged technical violation on wage statements. The bill states that if the alleged violation involves the wage statement’s inclusion of the name and address of the employer, or the inclusive dates of the pay period, then the employer shall have an opportunity to “cure” the violation before any PAGA claim may be filed.

AB 1506 was supported by the California Chamber of Commerce, which applauded Gov. Brown’s “fiscal prudence” in limiting “frivolous and potentially devastating” litigation against Golden State employers. “By allowing the employer a limited time period to fix technical violations on an itemized wage statement that does not create any injury to an employee before civil litigation is pursued, AB 1506 will enable an employer to devote its financial resources to expanding its workforce,” said a CalChamber report.

In a new study, WCIRB researchers have documented significant differences in the costs of claims among California regions. The Study found that the Los Angeles region experiences significantly higher claim frequency relative to the rest of California, while the Silicon Valley and San Francisco Bay Area regions experience lower claim frequencies. The Santa Monica – San Fernando Valley region is second, and San Gabriel Valley – Pasadena region is third highest. No opinion was provided to explain these differences.

WCIRB researchers also found that claim severities tend to be higher in the Central Valley and many of the urban coastal areas, but lower in the more remote, rural areas of the state.

The Study involved linking several diverse datasets which allowed the WCIRB to conduct a more refined analysis of geographical differences across California than has previously been possible. The Study examines geographical differences in:

– Indemnity frequency
– Total frequency
– Incurred indemnity on indemnity claims
– Median injured workers’ average weekly wages
– Incurred medical on indemnity claims
– Cumulative injury and occupation disease claims

The Study of Geographical Differences in California Workers’ Compensations Claim Costs and a mapping of nine-digit zip codes to the Study’s regions are available on the WCIRB website in the Research and Analysis section.